Older people not immune to substance abuse

While substance abuse is often perceived to be a problem of the young and reckless, it cannot be further from the truth. According to addiction psychiatrist Dr Parameswaran Ramasamy, one can become addicted to substances at any stage of life.

Substance use disorders (SUD) occur when the recurrent use of alcohol and/or drugs causes clinically significant impairment, including health problems, disability, and failure to meet major responsibilities at work, school, or home.

Parameswaran said: “You might think that as you grow older, you have more control over yourself. It’s not true, [substance abuse] can occur at any time and at any age.” Speaking at the 10^th Malaysian Hybrid Conference on Healthy Ageing 2022 in Penang, he noted that elderly patients without a background of opioid abuse have consulted him for addiction to benzodiazepines and opiates.  

It is a myth that older people are not at risk of developing substance abuse disorder. The common train of thought is that because the elderly was never involved in substance abuse when they were younger, the risk of getting addicted to substances become negligible in their old age. “It’s not true … they can occur at any time and age.” Unfortunately, there is a stigma with asking older patients whether they are at risk of developing substance abuse or if they are dependent on drugs, and thus it runs the risk of becoming a hidden illness.

Local prevalence data is scarce, noted Parameswaran. As a reference point, he quoted figures from the US, where about 3 percent of the general population suffered from alcohol addiction and this figure was much higher (22 percent) in the healthcare setting. Meanwhile, tobacco use ranked at 14 percent. Abuse of prescription, nonprescription and over-the-counter medications is widespread, with more than 35 percent of the general population resorting to substance abuse.  In Malaysia, the Ministry of Home Affairs recorded an average of 2,000 persons aged above 50 being arrested annually from 2013 to 2018. They were caught for illicit drug use, including amphetamine, cannabis, and opioids. Other substances commonly abused are kratom/ ketum (Mitragyna speciosa), benzodiazepines, and opioid-based painkillers.

Generally, many risk factors lead to substance abuse later in life. Males tend towards alcohol abuse while females steer towards prescription drug abuse. Contributing physical risk factors include chronic pain, poor health status, polymorbidity, among others. From a psychological perspective, those with a history of alcohol abuse, previous substance use disorder (SUD), or previous psychiatric illness are also at greater risk of substance abuse later in life. Beyond physical and psychiatric risk factors, social factors such as affluence, whether a person is suffering from bereavement, facing forced retirement, or in social isolation (for whatever reason), can increase a person’s substance abuse risk. Parameswaran noted that a patient’s affluence can contribute to substance abuse as they are able to pay and dictate that a doctor prescribes more than the usual recommended amount of drugs.  

Parameswaran said he utilized the DSM-5*criteria for diagnosing SUDs in older patients as it was straightforward. However, clinicians will have to consider other factors such as cognitive impairment (which may not be related to substance use) that can prevent self-monitoring during treatment. The complete list of criteria and considerations can be accessed here.

 

If the older patient is not forthcoming or does not realize they have SUD, clinicians can look for the following indicators of substance misuse and abuse. [Figure 1] The definition of misuse is use that contradicts medical advice or that is not as prescribed. This only applies to prescription or over-the-counter medication and only those for medical purposes. Abuse refers to the use of a drug for nontherapeutic reasons ie, recreation, to obtain psychotropic or euphoric effects. These uses also contradict medical advice or is not used as prescribed. Abuse also involves element or harm to the use or others and represents the illegal use of a drug. [Pain 2013; 154(11): 2287–2296]

Figure 1: Potential indicators of substance abuse or misuse.

With regard to substance abuse screening, Parameswaran reiterated the need to view it as part of continuum of healthcare and to screen for SUD during  annual health-checks. If it is obvious that a patient has SUD, clinicians may be more direct and ask if they have a problem with substance use, and whether they would be willing to change or are looking to change. It is then the clinician’s responsibility to provide education on the harm those substances can cause and resources for cessation.

Then it becomes a matter of continued checking and monitoring of the patient and once a diagnosis of SUD is confirmed, treatment can be initiated. Four types of treatments are used in SUD, including brief intervention, withdrawal management, medication-assisted therapy, and psychosocial treatment. While the patient is undergoing recovery, they should be provided with resources for relapse prevention. These include analysis of previous substance use behaviour to identify triggers and high-risk situations. The patient may be provided with skills to cope with triggers. Clinicians may also follow up with informal support in the form of telephone calls.

*DSM-5: Diagnostic and Statistical Manual of Mental Disorders 5^th Edition